Telemedicine in allergy/immunology in the era of COVID-19: a Canadian perspective

Background In the era of COVID-19, utilization of telemedicine has dramatically increased. In addition to reduced travel times, patient expenses, and work or school days missed, telemedicine allows clinicians to provide continued care while minimizing face-to-face interactions, maintaining social distancing, and limiting potential COVID-19 exposures. Clinical Immunology and Allergy (CIA), like many specialties, has adapted to incorporate telemedicine into practice. Previous studies have demonstrated similar patient satisfaction between virtual and in-person visits. However, evidence from fully publicly funded health care systems such as Canada has been limited. Methods We performed a quality improvement (QI) initiative to assess the feasibility of telemedicine. Between 1 March and 30 September 2020, patient encounters of two academic allergists at a single institution in London, Ontario, Canada were analyzed. Assessments were categorized into in-person or telemedicine appointments. A random sample of patients assessed virtually completed a voluntary patient satisfaction survey. Qualitative analysis was performed on survey comments. Results In total 3342 patients were seen. The majority were adults (n = 2162, or 64.7%) and female (n = 1872, or 56%). 1543 (46.2%) assessments were virtual and 1799 (53.8%) assessments were in-person. 67 of 100 random patient surveys sent to those in the virtual assessment group were completed. 89.6% (n = 60) agreed or strongly agreed when asked if they were satisfied with their telemedicine visit. 64.2% (n = 43) felt they received the same level of care compared to in-person assessments and 91% (n = 61) stated they would attend another virtual appointment. 95.4% (n = 62) of patients reported saving time with virtual assessment, the majority (n = 42, 62.7%) estimating between 1–4 h saved. Reported shortcomings included technical difficulties, “feeling rushed”, and missing in-person interactions. Conclusions Our quality improvement initiative demonstrated high patient satisfaction and time savings with virtual assessment in a publicly funded health care system. Studies suggest that CIA may be uniquely situated to benefit from permanent integration of virtual care into regular practice for both new and follow-up appointments. We anticipate continued increased utilization of telemedicine, signifying a lasting beneficial change in the delivery of healthcare.


Background
In response to the COVID-19 pandemic, unprecedented changes and progress have occurred in the distribution of healthcare services. One area at the forefront of advancement is virtual delivery of care through telemedicine [1,2]. Previously prioritized for patients living in remote areas with limited access to in-person

Open Access
Allergy, Asthma & Clinical Immunology  18:16 medical care, telemedicine has emerged as a viable option for even those living in urban settings [3]. Telemedicine reduces travel times, patient expenses, and work or school days missed [4,5]. In context of the global pandemic, it allows clinicians to provide continued care while minimizing face-to-face interactions, maintaining social distancing, and limiting potential COVID-19 exposures [2]. While the use of virtual medicine in Clinical Immunology and Allergy (CIA) was increasing prior to the COVID-19 pandemic, CIA, like many specialties, has recently adapted to further incorporate telemedicine into practice [1,2,6]. CIA specific studies from multiple countries have shown similar patient satisfaction between virtual and in-person visits [1,[6][7][8][9]. However, for telemedicine, evidence from fully publicly funded health care systems such as Canada has been limited. A recent Canadian study by Shiff et al. did demonstrate patient satisfaction to telephone appointments as an alternative at a urology clinic [10]. However, to date, little is known regarding CIA telemedicine and patient satisfaction in Canada.

Methods
We performed a quality improvement (QI) initiative to assess the feasibility of telemedicine. Between 1 March and 30 September 2020 inclusively, we analyzed patient encounters of two academic allergists at a single institution in London, Ontario, Canada. Assessments were categorized into in-person or telemedicine appointments. All telemedicine appointments were synchronous via telephone or video, scheduled at 15-20 min intervals. Patient demographics including gender, age (adult [≥ 18 years old] or pediatric [< 18 years old]), and primary diagnosis based on Ontario Health Insurance Plan (OHIP) Diagnostic codes (determined by the physician as the reason for consultation) were documented [11]. To determine patient perception of telemedicine, a random sample of initial consultations assessed virtually completed a voluntary patient satisfaction survey. For pediatric patients, these surveys were sent to the caregiver. Qualitative analysis was performed on submitted comments by 2 of the authors and confirmed by the rest of the authors of this manuscript.
Publicly available data from the local health unit was analyzed and the number of COVID-19 cases in the region was documented [12]. Overall case number trends in Ontario mirrored those of the local public health unit [13]. Figure. 1 displays by month the number of COVID-19 cases in the region and the number of assessments (in-person or virtual) completed by the clinic.
Out of 100 random patient surveys sent in the virtual assessment group (Table 2), 67 patients completed the survey. 60 patients (89.6%) agreed or strongly agreed when asked if they were satisfied with their telemedicine visit. 43 (64.2%) patients felt they received the same level of care compared to in-person visits. 55 (82.1%) believed telemedicine should be offered to all patients and 61 (91.0%) stated they would attend another telemedicine visit. 62 (95.4%) patients reported saving time with telemedicine assessment, the majority estimating between 1-4 h saved (n = 42, or 62.7%). Noted benefits of virtual clinics included shortened wait times and improved access to care, while shortcomings included technical difficulties, "feeling rushed", and missing in-person interactions.

Discussion
This is the first Canadian analysis of the implementation and continuation of telemedicine in a CIA practice during the COVID-19 pandemic. We note high levels of patient satisfaction after virtual assessment. 89.6% of survey respondents were satisfied with their telemedicine   [5]. 95.4% of our survey respondents reported time-savings with virtual assessment, the majority estimating between 1-4 h saved (n = 42, or 62.7%) with a median of 2-3 h saved per appointment. This equates to about 3528-7056 patient hours saved based on the virtual patients seen in our initiative.
However, 17.9% (n = 12) of our respondents did not feel like they received the same level of care as in-person visits and 1.5% (n = 1) were strongly dissatisfied after their telemedicine appointment. 9% (n = 6) indicated they would not attend another virtual appointment. Qualitative analysis identified technical difficulties, the feeling of being rushed, and missing in-person interactions as common themes for negative experiences with virtual assessments. These sentiments are similar to Thomas et al. 's study findings which noted negative experiences including feeling that the virtual assessment was "impersonal" compared to a face-to-face visits, low audio quality, and the need for a follow up in-person assessment for allergy testing [1]. Mustafa et al. found that the most commonly reported reason patients preferred face-to-face assessments was the desire for more personal interactions [7]. Our virtual appointments were booked at 15-20 min intervals. In the future, providing longer appointment times for virtual appointments may help reduce the feeling of being rushed. However, Thomas et al. retrospectively reviewed 537 virtual CIA appointments with an allocated appointment time of 20 min [1]. 1% of survey respondents after these assessments felt that the appointment duration was "about right" [1]. There are likely additional factors other than appointment duration that should be addressed to improve the virtual interaction. Moving forward, as telemedicine continues to be integrated into medical care, there should be a focus on minimizing technical disruptions and the perception of reduced interactions or compromised doctor-patient relationships [3].
In our clinic, virtual assessments continued at high levels even after temporary reductions in local COVID-19 case numbers and easing of restrictions (Fig. 1). Perhaps this indicates patient and/or provider satisfaction or preference for virtual visits. This data suggests that virtual assessments may continue at high levels postpandemic even as overall case numbers decline and restrictions lift.
Our QI initiative does have a few limitations. We were not able to send surveys to all virtually-assessed patients and given the anonymized and randomization of the survey results, we are unable to know whether the respondents are an adequate representation of the general population. However, we believe the sample from our randomly sent surveys and comments are representative of overall perception of virtual care as our results are in keeping with similar studies [1,[5][6][7][8][9]17]. We were not able to record other medical comorbidities of the patients given the methodology of our QI initiative. This is in keeping with previous similar CIA virtual care patient satisfaction survey studies [1,[5][6][7][8]17]. While our patient surveys were only sent to new consultation patients, Mustafa et al. noted similar high rates of patient satisfaction between new and follow-up patients in their study [7].
Our study did not assess patient outcomes or completeness of virtual encounters, but other studies have demonstrated that the virtual telemedicine modality is effective for both new and follow-up appointments in CIA. Thomas et al. determined that over 42% of new virtual allergy/immunology consults could be discharged from service after initial telemedicine assessment [1]. Waibel et al. found that over 75% of virtual CIA consultations did not require in-person follow up [5]. This indicates that a large proportion of new assessments can be completed without in-person visits or testing, likely because certain diagnoses are determined primarily through clinical history and review of medical records [3]. Studies have also demonstrated that CIA telemedicine follow-up appointments are effective, with fewer than 10% requiring in-person follow-up visits [1,5].
Despite the many advantages of virtual care, certain consultations will still require in-person assessment to help facilitate procedures such as skin testing and oral food or drug challenges. However, even for patients who do require in-person reassessment, initial virtual evaluation is highly beneficial and can lead to improved productivity and efficiency. Virtual assessments afford clinicians the opportunity to order relevant investigations, start medical therapy and evidence based management, and provide patient education [1][2][3]18]. By the time the patient is seen for in-person follow-up, all relevant investigations would be available and response to management could be assessed [6]. Any relevant drug/ medication preparations not typically stocked in clinic could also be ordered by this time for skin prick testing, intradermal testing, or drug challenges [1]. Certain patient presentations including chronic urticaria, non-IgE-mediated food reactions, atopic dermatitis, historical adverse drug reactions, asthma, allergic rhinitis, and immunologic conditions are thought to be particularly well suited for virtual assessment [2,3,6,18]. Future studies are needed to help address cost benefit analysis of telemedicine in Canada as well as its impact on wait times especially in a fully publicly funded health care system.

Conclusions
In the era of COVID-19, utilization of telemedicine has dramatically increased. Our QI initiative demonstrated high patient satisfaction along with time savings in a publicly funded health care system. Studies suggest that Clinical Immunology and Allergy may be uniquely situated to benefit from permanent integration of virtual care into regular practice for both new and follow-up appointments [1][2][3]18]. We anticipate continued increased utilization of telemedicine, signifying a lasting beneficial change in the delivery of healthcare.
Abbreviations CIA: Clinical immunology and allergy; QI: Quality improvement.